Table 5 Reported facilitators and barriers to program implementation, by PRISM domains

Program (intervention) domain

• Centralized screening outreach addressed primary care time constraints in offering screening

• Optimal choice of screening test (i.e., fecal testing or endoscopy) was unclear from evidence

• Adoption of FIT gave providers a fecal test method that they could more easily explain, addressing primary care time constraints

• Information technology department was not involved early enough in the process to determine best interfaces with EMR

• Improved accuracy of FIT enabled communication of more unified message about screening prioritization within the organization

• Slow response in mailing out fecal tests to those that accepted outreach impacted the efficiency of the program

• Incorporating automated screening reminder alert into electronic medical record built upon existing “care gap” reminder structure

• Increased compliance with new FIT kit unintentionally created access challenges with colonoscopy services for a while

• Incorporating automated screening reminder alert enabled support staff to offer screening during primary care office visits

External environment domain

• There was interest in increasing quality performance numbers (e.g., HEDIS measures) to the levels of those of other comparable health care organizations

• Alignment of automated reminders and fecal test orders with Medicaid and Medicare reimbursement regulations was challenging

Implementation infrastructure and sustainability domain

• Dedicated team for implementation had prior experience in implementing automated reminder programs for other health screening services

• There was a need to improve integration of program (e.g., documentation of centrally mailed FIT) within EMR

• Data showing increased screening rates supported effectiveness of program

• There was a need to improve staffing levels and training for ordering/mailing FIT kits centrally, and tracking diagnostic follow ups

• Recent emphasis on increasing capacity for colonoscopy enabled program to absorb increased number of colonoscopies

• There was a need to improve workflows and EMR documentation to decrease screening duplication errors

• Cross-department support and coordination between population care leaders, information technology, laboratory services, GI department, PCPs and support staff enabled maintenance and improvement of program

• There was a need to improve FIT kit instructions and labeling of FIT kits to decrease errors in test completion and processing

Recipients domain

• Strong leader, manager, clinician, specialist and frontline staff belief in the importance of CRC screening facilitated program acceptance

• There was an ongoing need to continue education and to shift habits of some providers/specialists away from colonoscopy as the only screening choice

• An historical cultural emphasis on screening helped the intervention to be perceived as an effective and important strategy worthy of continuing

• There was an ongoing need to clarify roles, processes and expectations between providers and specialists regarding positive screening follow-up issues

• Providers and staff felt more trained on and educated about CRC screening options and resource stewardship issues

• There was a continued need to provide performance data feedback and clear expectations regarding CRC screening rates and organizational preferences to all staff